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There are widespread calls for a public inquiry to learn lessons from the COVID19 pandemic that has inflicted the United Kingdom over that last 12 months. However, there is little recognition of the weakness in Public Inquiries as a learning process. From my research over that last ten years I have identified a number of weaknesses; these are listed below.


Having identified these weakness I examined the Moore-Bick Inquiry (part 1): my analysis can be found here. I predict that we shall see the same weaknesses in the Manchester Bombing Inquiry Report (currently underway) and the report of any future inquiry into COVID19.Time will tell: I hope I am wrong.


Key Public Inquiry Analytical Weaknesses that Hinder Learning from Crises:

  • Shutting the stable Door - Inquires often focus on preventing the problem that occurred rather than seeking lessons that will prevent similar things happening in the future. They seek to explain why the events in question occurred in the expectation they that by identifying flaws in the process, these can then be remedied and so prevent similar events happening in the future. The expectation that the rules should have worked, regardless of the context.

  • Blame Culture - They adopt a processual approach that seeks to determine which rules were broken and they prescribe these fails to comply as being the cause of the failure. They look to allocate blame (for supposed incompetence) as this is easier that finding the true cause within the complexing dynamics of the situation. Rarely is there any attempt at 'double-loop' learning to determine whether the rules were appropriate in the circumstances.

  • Seat of Understanding - Inquiry team come with their own set of biases. They tend to see the world through a legal rather than operational lens. This means that they often  fail to understand what they are seeing and hearing due to not having the necessary “seat of understanding” [Vaughan, 1996]. A lack of a seat of understanding would make Inquiry Team “pigs looking at watches” [Snook, 2000]; that is, intelligence creatures not able to recognise what they are seeing.

  • Paradigm Error -They to see the world as they would like it to be (where a perfect outcome can be achieved every time; this is labelled as the “perfect world‘ paradigm) rather than how it is (complex and mess; this is labelled as the “normal chaos” paradigm). The implications and unintended consequences of this error are fundamental and widespread: they are cover in more detail elsewhere on this website.

  • Foresight - While many inquiry teams state that they are aware of the problem of hindsight (the use of knowledge that can only have been known after the event in question), in their analysis they still confuse hindsight and foresight and this leads to erroneous analysis. This is especially important when it comes to the timing of decisions. For example, where a decision is seen to have been taken "too late" can only be a judgement in hindsight.

  • Systems approach - Inquiry teams fail to take a fully holistic view of the complex system involved; instead they look at individual interactions without considering their secondary effects. This approach leads to the failure to recognise true the forces at work that produced the undesirable outcome.

  • Context - They fail to take into account how the specific context create the unique circumstances that lead to the failure. Every event is unique in some way. To understand an event the analysis needs to understand how it differs form a perceived norm in order to firstly understand why the event manifested itself in the way it did and what general lessons may be extracted from the experience.

  • Full system dynamics. The fail to consider the full range of dynamics that acted to create the event in question. For example, with hindsight they can see the outcome required and the decisions that needed to have been taken. With this they criticise the decision-maker for not taking the right decision at the right time without consider all the factors that they considered or should have considered using the information available at the time.

  • Temporal Dimension - inquiries of fail to take into account the temporal dimension when it come to decision-making in a crisis. They fail to allow for the time it take to see, appreciate and then act. That is, the time is take to recognise and decide that what they see is significant; it take time to appreciate (decide) what the significance of the new data is and to decide on the action that needs to be take, and the to enact that plan. It also need to be noted that within this routine there will be many similar sub-routine that will also prolong the overall process. Al the major, minor and micro decisions that are need to enact a reaction to a stimulus will take time. Using knowledge of the required outcome gained through hindsight, inquiries often overlook this temporal dimension.

  • Interdependencies - They confused communications with interdependencies; that is, they concentrate on the failure to exchange data rather that understanding the imperatives within the relationships of identified parties and enabling them.

  • Control - Inquiry team often look to control events by centralising decision-make (through the use of 'rules'.) This can lead to ineffective local decision-making as seen at Grenfell Towers.


  • Relying on Rules - They resort to recommendations based on rules (consistent with a perfect world view) despite their inherent weaknesses: linked to the identification of failure to confront to rule sets.

  • Span of Control.  They assume that any competent leader is able to control every aspect of area of responsibility. They therefore equate failure with incompetence (and therefore see it as being appropriate to allocate blame). They do not therefore inquire into what control was possible or event desirable in the circumstance that prevailed at the time in question. In turn, this leads to recommendations that emphasis centralised control over more decentralised systems instead of have a proper debate over where the balance should have lain at the time and in the circumstance in question.

  • Poor Recommendations - Inquiry teams have difficulties in producing actionable recommendation; they generally produce “grand wishes” that leave an unacknowledged gap between the recommendation and its enactment ("non-equidistance").


  • Silver Bullets - They look for "one-time silver bullets" that will "solve" the problem in one step rather than accepting that many issues cannot be solved but can only be constantly managed.

  • Level of abstraction - They are more comfortable with and are therefore able to learn from issues that have direct cause /effect relationships (in other words are simple), are intangible and are technical. They are less effect when making recommendations concerning less tangible social (management) issues. The effect of this is that recommendations can be very general statements of intent (such as “communications must improve” to which no one can disagree as this is a universal problem) but reports rarely identify why that particular part of the system was not fit for purpose.

  • Non-equidistance of Recommendations - They fail to differentiate between recommendations that directly produce the outcome required and those that are only obliquely related to the outcome required.

  • Implementation - They have little appreciation of the time and efforts it will be needed to implement even the apparently most simple recommendations… "liability of newness" [Stinchcombe,1965] this terms embraces all the practical barriers that stand between somethings introduction and its successful implementation.

  • Drift. One of the key factors in failure is ‘drift’ in its many forms (where the system in place decouples from the circumstance it is supposed to manage) during the incubation period leading up to the events in question. This issue is rarely even considered and so recommendations become a repetition of what is already knowledge but offer little understanding of why organisations failure to learn from past experience.

Last Updated: 06 Nov 21

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